REPUBLIC OF THE PHILIPPINES)

CITY OF _______ ) S.S.

x-------------------------------------x

AFFIDAVIT OF SELF-ADJUDICATION

I, ________________, of legal age, Filipino, sinlge/married and a

resident of __________________________, after having been duly sworn to
in accordance with law, depose and state:

1. That I am the only child of _________________ who died without any last
will and testament on _________________ in
_________________________ as evidenced by his Death Certificate issued
by the City of _____________ hereto attached as Annex “A” and made an
integral part of this Affidavit;

2. That at the time his death, my father had no debts, liabilities or obligations to
any persons, agency or institution;

3. That the only property he left is a parcel of land consisting of ____________

square meters located in ___________________________ more particularly
described in OCT No. 1254 hereto attached as Annex “B” and made an
integral part of this Affidavit;

4. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby adjudicate
unto myself the above-described real estate by means of this Affidavit and
hereby files the same with the Register of Deed of __________________with
the request that the said adjudication be made effective without judicial
proceeding as prescribed by the aforementioned provision of the Rules
of Court.

IN WITNESS WHEREOF, I have hereunto set my hand this ____th day

of _______, 20__ in ________________, Philippines.

_________________________

SUBCRIBED AND SWORN TO before me this _______ day of _______,

2018 in Naga City, Philippines, affiant exhibiting to me his
_____________________issued on _______________ and valid
until _________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.